Wind

I woke up at least four times last night. Sometimes because I was cold, one time because I had to pee, but a number of times because of the sound of the wind whipping through my back yard, the wind chimes, the trees outside my windows, splashing water against the glass. And each time that wind woke me up I either dreamed or imagined all of my pregnant patients getting whipped around, the wind pushing them over, and my patients struggling to stand up, their bellies emptied by the force of the gusts…Every time I thought or dreamed of them I got anxious and sweaty and mad that I was awake. I’d put my head back down on the pillow hoping to drift back off but I’d just lie there, visions of pregnant women and their babies and this sick feeling inside me. So when my alarm finally went off I felt like I had never gone to sleep. My eyes were swollen, my body was tired and the last thing I wanted to do was head into the office and see patients.

Turns out, the wind had blown in a number of medically and emotionally trying people. A 41 yo at 8.4 wks came in first thing c/o abd cramping and light pink spotting. An US showed she had a 6.1 wk pregnancy with no fetal heartbeat. And here’s me, having only dealt with a handful of missed ABs and knowing that there are options for her: expectant mgt vs miso vs d and c but I’m not sure if there is a practice protocol, I’m not sure what the dosages are of miso if I choose to offer that and there are no docs in the office to ask. It’s annoying more than anything else. The CNM says D and C though I know the doc who I usually bring my questions to sometimes does miso until 8 or 9 weeks…it’s just so hard to know what is RIGHT. I find myself wanting to know things in black and white. Just, tell me what to do. Just tell me yes or no, wrong or right. Tell me the parameters. The protocols. The rules. But in so many cases there is no clear right or wrong, your mgt should depend on the patient’s issues and needs, on which doc is in the office, on so so so many things. And it just makes it so damn hard to learn sometimes. In the end, it was a moot point for this patient. The idea of any sort of expectant management made her shudder. She opted for the simple outpatient procedure and my management became clear. But still, what do I do when it happens again?

One of my teen patients came in for her first OB appt later in the morning. She had seen me last week for her first OB appt but because she was unsure at the time about whether or not she wanted to keep the pregnancy that appt turned into a “what are my options/how do I tell my parents” appt. I thought at the time that there was about a 50/50 chance she’d be back, still pregnant. I kept waiting for her appt to disappear from my roster. Kept waiting to get a phone call saying she had gone to planned parenthood for a TAB and wanted to schedule a f/u appt with me. But no, her name stayed right there. And she showed up right on time for her appt. But before she got there I received a phone call from her mother. She was very clear with me from the beginning that she knew, since her daughter was 18, that she couldn’t get any information from me about her medical care. But she wanted to…well, it honestly sounded like she wanted to warn me about her daughter. She proceeded to tell me that her daughter has significant psych issues, anger issues, run-ins with the law, she called her narcissistic and selfish. She said her younger sister hates her because of how she has acted, she told me she flunked out of college, had been living at home, has had bursts of anger so intense that her mother has had to hide from her in the basement…she asked for resources, she asked if I thought it was a good idea that her daughter have a baby. She told me that she and her husband had made it clear that if she decides to keep the pregnancy she is no longer invited to live under their roof. And I couldn’t say anything. Couldn’t share any information, couldn’t share my opinions about her daughter. Mentioned a few things I typically talk about with pregnant patients who also happen to be teenagers…but our “conversation” was one sided. She was telling me all of the reasons her daughter should not be a mother and I just sat there and listened. And while I listened I was handed a fax from her that she had sent me just before our phone call marked “Urgent” which was a 2 page list of all of the things her daughter has done “wrong” essentially. Things like: Has become accustomed to having parents who ENABLE her bad habits, Repeated episodes of ANGER, Almost FLUNKED out of high school. The list went on and on like this with words that she didn’t want me to miss capitalized and italicized. I read and I listened all at the same time. And I got sick to my stomach. Why WAS this girl having a baby? Why were her parents throwing her out? Why did all the comments on this list sound like name calling? What was I supposed to say to this woman? What was I supposed to say to her daughter when she came to see me? I definitely couldn’t tell her that I had spoken with her mom, and letting her know her mother had sent me a 2 page document convincing me how evil her daughter was would certainly only make the situation worse. I said goodbye to the patient’s mother having only been able to listen and not able to provide her with any reassurance that I could talk her daughter out of staying pregnant.

When I met with the patient she was happy and smiling, confident that she had made the right decision to keep the pregnancy. Her boyfriend, not with her today, was going to be supportive but he won’t tell his parents. She told me that her mother forbid her to stay in the house. She told me that she felt prepared to find a room for rent, that she made enough money working bussing tables at 2 different restaurants to pay for a place. She told me she had been on a bunch of psych meds but didn’t want to be taking them during her pregnancy so, once she found out, just stopped taking them cold turkey. But she was feeling good, she would f/u with her therapist, she was also considering giving the baby up for adoption. She was appropriate, respectful, happy, articulate, forthcoming and, I thought, honest. But this young woman, sitting on the exam table, was literally the exact opposite of the girl her mother had described over the phone and in the fax. Was this part of the act? Was I seeing a side of my patient that her mother couldn’t see? That the pt couldn’t show to her mother? She seemed so together. Young, yes, but together. And then I started her exam. Thyroid palpated nml. All the lymph nodes in her neck, above and bellow her collar bone, nml, non palpable. Her lungs were CTAB. And then I laid my stethoscope on her chest and told her to breathe normally. And there is was. A racing heart. Her pulse must have been in the 80s at rest. And I thought, in that moment, well, here is something real. Whether she is excited, scared, worried, panicked… whatever the emotion, there was something there.

“So, how are you doing with all this?” I asked after the exam.

“Fine.” She said smiling, waiting for the next question and kicking her heels back against the exam table she was sitting on.

“Just fine?” I asked.

“Yeah, I guess. I don’t know. I don’t know.”

At the end of the visit the patient was certain she did not want to give her consent for her mother to speak with me about her pregnancy but she said she would let me know if she changed her mind.

I finished the day with a little abdominal pain at 14 wks, intermittent vaginal itching and a wicker broom-like pattern under the microscope that I had never seen before, and one, yes one, nml return OB visit at 32 wks.

I’m hoping, as I do on so many nights, to sleep without waking up until morning. Hoping to not dream about patients, hoping to not hear the wind.